Lacis Mail Order Form

This form can be printed and used for ordering.

Name _______________________________________________________ Date ________________
Please include street address and Po Box # if available.

Address 1_________________________________________________________________________

Address 2_________________________________________________________________________

City, State, Zip _____________________________________________________________________

Phone ______________________________ E-mail ________________________________________

Payment is being made by:
___ Check/Money Order ___ Credit Card [ ___ Visa ___ Master Card ]

Card Number ___________________________________________________ Exp_______________

Signature ________________________________________________________

Qty   Code      Description                           Price   Extension

____  ________  _____________________________________________  ________ __________

____  ________  _____________________________________________  ________ __________

____  ________  _____________________________________________  ________ __________

____  ________  _____________________________________________  ________ __________

____  ________  _____________________________________________  ________ __________

____  ________  _____________________________________________  ________ __________

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____  ________  _____________________________________________  ________ __________

                                                             Sub Total  __________

                                                         Tax (CA only)  __________

                                                   Shipping ($4.00 min) __________

                                                   Insurance ($.75 min) __________

                                                      Previous Balance  __________

                                                                Payment __________
LACIS
3163 Adeline St.
Berkeley, CA 94703

tel: (510) 843-7178
fax: (510) 843-5018